The new face of AIDS

The Economist, TNNNov 27, 2004, 01.16AM IST

Charlene Smith, a South African woman who was raped in 1999, has since then campaigned against sexual violence and for the free provision of anti-retroviral drugs to prevent rape victims contracting HIV, the virus that causes AIDS. Neither of these stances, you might imagine, would be controversial.

But both have enraged South Africa's president, Thabo Mbeki, who accuses Ms Smith, who happens to be White, of spreading the racist myth that African men are "rampant sexual beasts, unable to control our urges, unable to keep our legs crossed, unable to keep it in our pants," as he told the country's parliament last month.

The latest report on the global AIDS epidemic, released by UNAIDS this week, makes depressing reading, as usual.

There were an estimated 4.9m new infections in '04, and 3.1m people died of AIDS. About 40m people are now infected, a small majority of whom are male.

But women are catching up fast. In sub-Saharan Africa, 57% of those infected are female. Among young South Africans, Zambians and Zimbabweans, the figure is three-quarters.

UNAIDS and the WHO publish their annual 'AIDS Epidemic Update'.

To fight the disease, one has to understand how it spreads. And one of the most striking aspects of the virus's passage from male to female bloodstreams is how little say women have had in the matter. Men tend to contract HIV because of things they have done; women are more likely to contract it because of things that have been done to them.

Rape is part of the problem. Violent, bloody sex is much more likely to result in infection than the consensual variety, and is much more common than many people believe.

In rural Peru, for example, 24% of young women say they lost their virginity to a rapist. In a recent national survey in South Africa, 10% of sexually experienced young women said they had been raped.

Less obviously, domestic violence contributes to the spread of HIV. Women whose husbands or boyfriends beat them are more likely to be infected.

This may be because men who beat their wives are also likely to be inconsiderate in other ways, such as sleeping with prostitutes and not caring whether this endangers their wives.

Or it may be because beaten women are often too afraid to say no to sex, or to ask their partners to use condoms. In Zambia, for example, only 11% of women thought they had a right to ask their husband to wear a condom, even if they knew he was unfaithful and HIV-positive.

AIDS specialists are sceptical about the efficacy of promoting sexual abstinence (a policy advocated by the American government), but Kathleen Cravero, UNAIDS's deputy director, thinks governments should be promoting the "right to abstain".

Mr Mbeki says this makes her a racist, but there may be something in the idea. Programmes teaching schoolgirls that they have a right to say no, and explaining to schoolboys that they have a duty to listen, are being tried out in Uganda and South Africa. It helps if both sexes are also taught how to talk to each other, and how to deal with relationships.

In general, the less educated a woman is, the greater the risk she will contract HIV. And ignorance about sex and AIDS is widespread. In Vietnam, two-thirds of young women could not name three methods of avoiding AIDS.

In rural Uttar Pradesh 83% of married women surveyed said that before they moved in with their husbands, they did not know how women become pregnant.

Educated women tend to be more assertive, partly because they tend to earn more and so are less dependent on their husbands. UNAIDS argues for the abolition of primary- and secondary-school fees, not only because it would make it easier for impoverished girls to attend school, but also because it would remove an important incentive to sell sex.

In several poor countries, most women who engage in prostitution, or who form relationships with older "sugar daddies", do so in order to pay school fees; either for themselves or for their siblings or children.

Sex between old men and young women is a crucial factor in the spread of the epidemic. A survey in Kenya, for example, found that among women whose husbands were no more than three years older, none was HIV positive, but among those whose husbands were a decade or more older, half were.

Wealthy older men can afford many sexual partners, and often prefer them young. Their dalliances with younger women keep the virus circulating between generations. Young women are at greater risk of contracting HIV, because the lining of the neck of an immature womb is less tough.

It does not help that many old men believe that because younger women are "pure", they need not wear condoms. Nor does it help that some believe they can cure themselves of venereal diseases by sleeping with a virgin.

Economic inequality between the sexes aggravates matters. The burden of caring for AIDS-sick husbands and children falls almost entirely on women.

In Africa and South Asia, discriminatory inheritance customs mean that when a husband dies, his family may grab the property, leaving his widow, who may be infected, penniless as well. She may then sell her body to survive.

Many of these problems would abate if people were richer. Women are less inclined to put up with abusive husbands when they can easily find jobs. Prostitution is rarer when it is not the only alternative to destitution.

But the economies of many of the countries worst-affected by AIDS are, partly as a consequence of the epidemic, growing slowly or not at all. And a disease that creates the conditions that favour its spread is the most dangerous disease of all.